Nokea
The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider?
- A. Hypoactive bowel sounds in the lower quadrant.
- B. Rebound tenderness in the upper quadrants.
- C. Tympany with percussion of the abdomen.
- D. Light-colored gastric aspirate via the nasogastric tube.
Correct Answer: B
Rationale: Rebound tenderness in the upper quadrants may indicate peritonitis, which requires prompt medical attention. Hypoactive bowel sounds are expected in small bowel obstruction and would not be a priority over signs of peritonitis. Tympany with percussion is a normal finding and not a cause for immediate concern. Light-colored gastric aspirate could indicate various issues but is not as urgent as peritonitis.
You may also like to solve these questions
A female client with major depressive disorder tells the nurse she feels worthless and can't see how her life will ever get better. What is the best response by the nurse?
- A. I can understand how you feel. Tell me more about what's been going on.
- B. You're going through a tough time. Let's discuss what makes you feel this way.
- C. You sound very hopeless right now. Are you thinking about harming yourself?
- D. It's difficult to see the light when you're feeling this way, but I'm here to help you.
Correct Answer: C
Rationale: Choice C is the best response because it directly addresses the client's expressed hopelessness and assesses the risk for self-harm. When a client with major depressive disorder expresses feeling worthless and unable to see improvement, it is essential to assess suicidal ideation to ensure their safety. Choices A, B, and D provide empathy and support, which are important but addressing suicidal ideation is the priority in this situation.
The healthcare provider is assessing a client with left-sided heart failure. Which laboratory value should be closely monitored?
- A. Serum sodium level
- B. Serum potassium level
- C. Serum creatinine level
- D. Serum glucose level
Correct Answer: B
Rationale: In a client with left-sided heart failure, monitoring serum potassium levels is crucial. This helps in assessing kidney function and fluid balance. Elevated potassium levels can result from impaired kidney function, which is common in heart failure. Monitoring sodium levels (choice A) is important in heart failure but not specifically related to left-sided heart failure. Serum creatinine (choice C) reflects kidney function but is not the most critical value to monitor in this case. Serum glucose level (choice D) is important but not the priority when assessing left-sided heart failure.
The nurse is caring for a client with chronic heart failure who is receiving furosemide (Lasix). Which laboratory value requires immediate intervention?
- A. Serum potassium of 3.0 mEq/L
- B. Serum sodium of 135 mEq/L
- C. Serum creatinine of 1.8 mg/dL
- D. Blood glucose of 200 mg/dL
Correct Answer: A
Rationale: A serum potassium level of 3.0 mEq/L is most concerning in a client receiving furosemide as it indicates hypokalemia, which requires immediate intervention. Hypokalemia can lead to serious cardiac arrhythmias, which can be life-threatening. Serum sodium of 135 mEq/L and serum creatinine of 1.8 mg/dL are within normal ranges and do not require immediate intervention in this case. Blood glucose of 200 mg/dL is elevated but does not pose an immediate threat to the client's life in the context of heart failure and furosemide therapy.
A client with a history of chronic heart failure is admitted with shortness of breath. Which laboratory value should be closely monitored?
- A. Serum sodium level
- B. Serum potassium level
- C. Serum creatinine level
- D. Hemoglobin level
Correct Answer: B
Rationale: Corrected Rationale: In a client with chronic heart failure, serum potassium levels should be closely monitored to assess for hyperkalemia, which can worsen heart failure. Monitoring serum sodium levels is not the priority in this case. Serum creatinine level monitoring is more related to kidney function than heart failure. Hemoglobin levels are important but not the primary concern when assessing heart failure exacerbation.
A male client with diabetes mellitus type 2, who is taking pioglitazone PO daily, reports to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellowish cast to his skin. What instructions should the nurse provide?
- A. Seek immediate medical assistance to evaluate the cause of these symptoms.
- B. Discontinue the medication and follow up with a healthcare provider.
- C. Increase fluid intake and monitor urine color.
- D. Continue taking the medication and report any changes.
Correct Answer: A
Rationale: The correct answer is A: 'Seek immediate medical assistance to evaluate the cause of these symptoms.' The symptoms described by the client, including nausea, dark-colored urine, and yellowish skin, are indicative of possible liver toxicity, a serious side effect of pioglitazone. Therefore, immediate medical evaluation is necessary to assess the severity of the condition and prevent further complications. Choices B, C, and D are incorrect: B advises discontinuing the medication without seeking immediate medical assistance, which could delay necessary treatment; C focuses solely on increasing fluid intake and monitoring urine color, overlooking the urgency of the situation; and D suggests continuing the medication when prompt evaluation is crucial in this scenario.